Group Health Continuation Notice and Election (See reverse side of this form for Other Health Coverage Options.) To (Name) Address City State ZIP Code Date From (Group Policyholder Name) Address City State ZIP Code Group Policy Number Continuation of Group Health Coverage is available to you due to: (Check one of the following) The employee’s termination of employment on The employee’s death on The employee’s divorce or legal separation effective The Group Health coverage under which you have been covered will cease because of the reason and on the date indicated above unless you comply with requirements 1 and 2 below. 1. Prior to (within 31 days after the above event or date of this notice, whichever is later), you must complete the Request/Refusal Statement below and return it to our Company. If you elect to continue coverage, you must submit to the address above, your check, payable to our Company, to cover the initial payment. The check must cover the number of months from the above event to the time of the payment. The currently monthly cost of the group health plan is: Medical $__________for the employee $__________for the dependent(s)** $__________total Medical premium Dental $__________for the employee $__________for the dependent(s)** $__________total Dental premium **Only those dependent(s) insured at the time of the termination of employment, the death of the employee, or the divorce are eligible for continuation. If you are a former employee, you may continue coverage for yourself only, or yourself and your covered dependents, or your dependent(s) only. If you are a surviving/divorced spouse, you may continue coverage for yourself only or for yourself and your covered dependents. If you are a surviving child, you may continue coverage for yourself only. 2. You must submit the same payment (unless you have been advised of a change) to our Company no later than the of each following month. If you fail to make the monthly payment when due, your coverage will cease at the end of the period for which payment has been made and cannot be reinstated. Respond immediately to assure early reinstatement of coverage and minimum claim delay If you make monthly payments as indicated above, your group health coverage will continue for 18 months provided, this Group Medical/Dental policy remains in force and you do not become eligible for full coverage under another group medical/dental plan. If you become eligible for other Group medical/dental coverage, you must notify us of the date of such eligibility. Also, you should not submit a monthly payment following this date. If you or one of your insured dependents becomes eligible for Medicare during the period you are continuing coverage, our Medical benefits will take Medicare benefits into account in the same manner as they would have been taken into account had your coverage not terminated. This continuation does not apply to any other coverage for which you were insured by reason of employment with our Company. Authorized Company Representative Request/Refusal Statement I request that my Medical coverage be continued myself only my dependent(s) only myself and my dependents I request that my Dental coverage be continued myself only my dependent(s) only myself and my dependents I do not want my Group Medical Dental coverage continued. Employee Signature Dependent or Surviving / Divorced Spouse Signature Date Return this form to the Policyholder address indicated above. Provided or administered by Aetna Life Insurance Company and/or its affiliates (collectively “Aetna”) GR-61909 CO (8-19) Page 1 of 6
Transcript
Group Health Continuation Notice and Election
(See reverse side of this form for Other Health Coverage Options.)
To (Name)
Address
City State ZIP Code
Date
From (Group Policyholder Name)
Address
City State ZIP Code
Group Policy Number
Continuation of Group Health Coverage is available to you due to: (Check one of the following)
The employee’s termination of employment on
The employee’s death on
The employee’s divorce or legal separation effective
The Group Health coverage under which you have been covered will cease because of the reason and on the date indicated above unless you comply with requirements 1 and 2 below.
1. Prior to (within 31 days after the above event or date of this notice, whichever is later), you must complete the Request/Refusal Statement below and return it to our Company. If you elect to continue coverage, you must submit to the address above, your check, payable to our Company, to cover the initial payment. The check must cover the number of months from the above event to the time of the payment. The currently monthly cost of the group health plan is:
Medical
$__________for the employee
$__________for the dependent(s)**
$__________total Medical premium
Dental
$__________for the employee
$__________for the dependent(s)**
$__________total Dental premium
**Only those dependent(s) insured at the time of the termination of employment, the death of the employee, or the divorce are eligible for continuation.
If you are a former employee, you may continue coverage for yourself only, or yourself and your covered dependents,or your dependent(s) only.
If you are a surviving/divorced spouse, you may continue coverage for yourself only or for yourself and your covered dependents. If you are a surviving child, you may continue coverage for yourself only.
2. You must submit the same payment (unless you have been advised of a change) to our Company no later than the of each following month. If you fail to make the monthly payment when due, your coverage will cease at the end of the period forwhich payment has been made and cannot be reinstated.
Respond immediately to assure early reinstatement of coverage and minimum claim delay
If you make monthly payments as indicated above, your group health coverage will continue for 18 months provided, this Group Medical/Dental policy remains in force and you do not become eligible for full coverage under another group medical/dental plan. If you become eligible for other Group medical/dental coverage, you must notify us of the date of such eligibility. Also, you should not submit a monthly payment following this date.
If you or one of your insured dependents becomes eligible for Medicare during the period you are continuing coverage, our Medical benefits will take Medicare benefits into account in the same manner as they would have been taken into account had your coverage not terminated. This continuation does not apply to any other coverage for which you were insured by reason of employment with our Company.
Authorized Company Representative
Request/Refusal Statement
I request that my Medical coverage be continued myself only my dependent(s) only myself and my dependents
I request that my Dental coverage be continued myself only my dependent(s) only myself and my dependents
I do not want my Group Medical Dental coverage continued.
Employee Signature Dependent or Surviving / Divorced Spouse Signature
Date
Return this form to the Policyholder address indicated above. Provided or administered by Aetna Life Insurance Company and/or its affiliates (collectively “Aetna”)
GR-61909 CO (8-19) Page 1 of 6
Other Health Coverage Options
You can purchase coverage on your own
You may be able to buy an individual health policy from other health insurance companies that offer these policies in your
state. These plans cover pre-existing conditions and you cannot be turned down. You will need to apply for an individual plan
within 60 days from the date your group coverage ends. You can buy these plans online or through a licensed health
insurance representative. To purchase an individual plan, you can visit eHealth.com.
eHealth is a licensed insurance agency that offers plans from many insurance companies along with tools to help you select
the plan for your needs and budget. You can also work with a licensed agent to get help finding a plan.
The Health Insurance Marketplace (Exchange) gives you a way to buy health insurance
You may be able to buy coverage through the Health Insurance Marketplace. The Marketplace will help you find health
insurance that meets your needs and budget. It offers "one-stop shopping" to find and compare private health insurance
options. You could be eligible for a tax credit that will lower the monthly cost right away. You can find out the monthly cost,
the deductibles and out-of-pocket costs of a plan before deciding to enroll.
For more information, visit www.healthcare.gov. Here you can get an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.
Administrative Instructions for Continuation of Medical Coverage
All Policyholders
Prepare an original and one copy of form GR-61909 CO for each individual to be terminated.
1. If there is any question of the proper premium, check with our local Aetna office.
2. Give or mail the original copy of the form to the terminated individual.
Notes
1. Medical and/or Dental coverage may be continued. If Dental coverage is issued as a separate benefit, it will be continued as a separate benefit. If Dental coverage is not issued as a separate benefit, meaning it is issued as part of a Major Medical or Comprehensive Medical plan, it too is continued.
Dutch Voor gratis taaldiensten, bel het nummer op uw ziekteverzekeringskaart.
French Pour accéder gratuitement aux services linguistiques, veuillez composer le numéro indiqué sur votre carte d'assurance santé.
French Creole (Haitian)
Pou ou jwenn sèvis gratis nan lang ou, rele nimewo telefòn ki sou kat idantifikasyon asirans sante ou.
German Um auf den für Sie kostenlosen Sprachservice auf Deutsch zuzugreifen, rufen Sie die Nummer auf Ihrer ID-Karte an.
Greek Για πρόσβαση στις υπηρεσίες γλώσσας χωρίς χρέωση, καλέστε τον αριθμό στην κάρτα ασφάλισής σας.
Gujarati
Hawaiian No ka walaʻau ʻana me ka lawelawe ʻōlelo e kahea aku i ka helu kelepona ma kāu kāleka ID. Kāki ʻole ʻia kēia kōkua nei.
Hindi
Hmong Yuav kom tau kev pab txhais lus tsis muaj nqi them rau koj, hu tus naj npawb ntawm koj daim npav ID.
GR-61909 CO (8-19) Page 4 of 6
Igbo Inweta enyemaka asụsụ na akwughi ụgwọ obụla, kpọọ nọmba nọ na kaadi njirimara gị
Ilocano Tapno maakses dagiti serbisio ti pagsasao nga awanan ti bayadna, awagan ti numero nga adda ayan ti ID kardmo.
Indonesian Untuk mengakses layanan bahasa tanpa dikenakan biaya, silakan hubungi nomor telepon di kartu asuransi Anda.
Italian Per accedere ai servizi linguistici senza alcun costo per lei, chiami il numero sulla tessera identificativa.
Japanese 無料の言語サービスは、 IDカードにある番号にお電話ください。
Karen
Korean 무료 다국어 서비스를 이용하려면 보험 ID 카드에 수록된 번호로 전화해주십시오.
Kru-Bassa I nyuu kosna mahola ni language services ngui nsaa wogui wo, sebel i nsinga i ye ntilga i kat yong matibla
Kurdish دی( ئای سهرژمارەی به دی بکههيوەنبۆ تۆ، پت چوون بهب زمان اریزتگوخزمهتن به اگهيش ID) بۆ دەسپ
.خۆتارتی ک
Lao
Marathi
Marshallese Ņan bōk jipan kōn kajin ilo an ejjeļọk wōņean nan kwe, kwōn kallok nōṃba eo ilo kaat in ID eo aṃ.
Micronesian-Ponapean
Pwehn alehdi sawas en lokaia kan ni sohte pweipwei, koahlih nempe nan amhw doaropwe en ID.
Mon-Khmer, Cambodian
Navajo
Nepali
Nilotic-Dinka Të kɔɔr yïn ran de wɛɛr de thokic ke cïn wëu kɔr keek tënɔŋ yïn. Ke yïn cɔl ran ye kɔc kuɔny në namba de abac tɔ në ID kard duɔn de tïït de nyin de panakim kɔu.
Norwegian For tilgang til kostnadsfri språktjenester, ring nummeret på ID-kortet ditt.
Pennsylvanian-Dutch
Um Schprooch Services zu griege mitaus Koscht, ruff die Nummer uff dei ID Kaart.
Persian Farsi
Polish Aby uzyskać dostęp do bezpłatnych usług językowych, należy zadzwonić pod numer podany na karcie identyfikacyjnej.
Portuguese Para aceder aos serviços linguísticos gratuitamente, ligue para o número indicado no seu cartão de identificação.
Punjabi
Romanian Pentru a accesa gratuit serviciile de limbă, apelați numărul de pe cardul de membru.
Russian Для того чтобы бесплатно получить помощь переводчика, позвоните по телефону, приведенному на вашей идентификационной карте.
GR-61909 CO (8-19) Page 5 of 6
Samoan Mō le mauaina o 'au'aunaga tau gagana e aunoa ma se totogi, vala'au le numera i luga o lau pepa ID.
Serbo-Croatian Za besplatne prevodilačke usluge pozovite broj naveden na Vašoj identifikacionoj kartici.
Spanish Para acceder a los servicios lingüísticos sin costo alguno, llame al número que figura en su tarjeta de identificación.
Sudanic Fulfulde Heeɓa a naasta nder ekkitol jaangirde woldeji walla yoɓugo, ewnu lamba je ɗon windi ha do ɗerowol maaɗa.
Swahili Kupata huduma za lugha bila malipo kwako, piga nambari iliyo kwenye kadi yako ya kitambulisho.
Syriac-Assyrian
Swahili Kupata huduma za lugha bila malipo kwako, piga nambari iliyo kwenye kadi yako ya kitambulisho.
Tagalog Upang ma-access ang mga serbisyo sa wika nang walang bayad, tawagan ang numero sa iyong ID card.
Telugu
Thai
Tongan Kapau ‘oku ke fiema’u ta’etōtōngi ‘a e ngaahi sēvesi kotoa pē he ngaahi lea kotoa, telefoni ki he fika ‘oku hā atu ‘i ho’o ID kaati.
Turkish Dil hizmetlerine ücretsiz olarak erişmek için kimlik kartınızdaki numarayı arayın.
Ukrainian Щоб безкоштовнj отримати мовні послуги, задзвоніть за номером, вказаним на вашій ідентифікайній картці.
Urdu
Vietnamese Để sử dụng các dịch vụ ngôn ngữ miễn phí, vui lòng gọi số điện thoại ghi trên thẻ ID của quý vị.
Yiddish
Yoruba Láti ráyèsí àwọn iṣẹ èdè fún ọ lọfẹẹ, pe nọmbà tó wà lórí káàdì ìdánimọ rẹ.
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